Market Applicability/Effective Date Market FL FL FL GA KS KY LA MD NJ NV NY TN TX WA & MMA LTC FHK Applicable X NA NA X NA X X X X X X NA NA X

Medication Quantity Limits Alamast (pemirolast potassium) 10mL/30 days Alocril (nedocromil sodium) 5mL/30 days Alomide (lodoxamide tromethamine) 10mL/30 days Bepreve (bepotastine besilate) 10mL/30 days Emadine (emedstine difumarate) 5mL/30 days Lastacaft (alcaftadine) 3mL/30 days Pataday (olopatadine hydrochloride) 2.5mL/30 days Patanol (olopatadine hydrochloride) 5mL/30 days Pazeo (oloptadine hydrochloride) 2.5mL/30 days

OVERRIDE(S)

Prior Authorization of Benefits Quantity Supply for Plans with Quantity Limits

APPROVAL DURATION

1 Year

APPROVAL CRITERIA

Requests for non-preferred ophthalmic allergy product may be approved for individuals who meet the following criteria:

I. Documentation is provided for trial of ALL preferred ophthalmic allergy products; A. Cromolyn; B. Ketotifen; C. Azelastine; D. Epinastine; E. Allergy Eye; F. Eye Itch Relief; G. Itchy Eye;

PAGE 1 of 2 04/03/2015 This policy does not apply to health plans or member categories that do not have pharmacy benefits, nor does it apply to Medicare. Note that market specific restrictions or transition-of-care benefit limitations may apply.

WEB-PEC-0337-15

Market Applicability/Effective Date Market FL FL FL GA KS KY LA MD NJ NV NY TN TX WA & MMA LTC FHK Applicable X NA NA X NA X X X X X X NA NA X

-AND-

II. Individuals’ symptoms continue despite treatment with the preferred ophthalmic allergy products.

Note: Zaditor (ketotifen) is available only as an OTC product and could be considered as a first line product prior to trial of prescription products.

May approve additional bottle(s) when quantity limit will NOT be sufficient for a 30 day period. Ask for dosage and quantity needed. Note: Drop sizes may vary, more than one eye may be affected and drops may be wasted due to difficulty in administration.

Requests for additional increased quantities will be reviewed on a case by case basis.

Documentation includes, but is not limited to, chart notes, prescription claims records, prescription receipts, and laboratory data.

PAGE 2 of 2 04/03/2015 This policy does not apply to health plans or member categories that do not have pharmacy benefits, nor does it apply to Medicare. Note that market specific restrictions or transition-of-care benefit limitations may apply.

WEB-PEC-0337-15